Please contact us at 415-386-2604 if your camper(s) is/are traveling unaccompanied and you want to discuss transportation options.

Parent/Guardian Info

Parent/Guardian's name *

First

Last

Parent/Guardian phone number *

Parent/Guardian's email *

Zip code *

Parent/Guardian's name

First

Last

Parent/Guardian phone number

Parent/Guardian's email

Zip code (copy)

Please check this box if you do not want your camper(s) listed in the Camp Be'chol Lashon Roster, which is only distributed to campers and their families.

How did you hear about Camp Be'chol Lashon? *

Word of mouth

Be'chol Lashon website/social media

Be'chol Lashon newsletter

School/Synagogue

Previously attended CBL

Other

Please specify:

Payment

You have the option to pay a $300 deposit or the entire camp fee at this time. You must pay at least the deposit to secure your child's spot. If you choose to pay the deposit only, you will be billed for the balance.

What would you like to pay today? *

Camp session(s) for first camper: *

Session 1

Session 2

Sessions 1 & 2

Bedding for first camper: *

No bedding

1 week

2 weeks

Camp session(s) for second camper: *

Session 1

Session 2

Sessions 1 & 2

Bedding for second camper: *

No bedding

1 week

2 weeks

Camp session(s) for third camper: *

Session 1

Session 2

Sessions 1 & 2

Bedding for third camper: *

No bedding

1 week

2 weeks

Total

$ 0.00

Credit Card *

Card Number

Security Code

Name on Card

Expiration/

Please note: Any camper who is unable to attend camp for any reason will receive full credit, minus the deposit, to be applied toward any other Be’chol Lashon program, including camp next year.

Emergency Contact

We will contact this person in the event that the parent/guardian listed above is not available.

Primary emergency contact's name *

First

Last

Relationship to camper *

Phone *

Address *

Address Line 1

City

State

Zip Code

Additional emergency contact's name

First

Last

Relationship to camper

Phone

Address

Address Line 1

City

State

Zip Code

Medical Info

Insurance company *

Policy number *

Group number *

Policy holder's name *

First

Last

Physician's name *

Physician's phone *

Dentist's name *

Dentist's phone *

Date of camper's last tetanus shot//

Medications

Name of medication(s)/supplement(s), dosage, and directions for use: *

Please note: All medications your child takes, including over the counter, as needed, and prescription need to be brought in a sealed container or plastic bag with their name and directions for use. There must be enough medication (prescription and over the counter) to last the duration of camp. Unused medication will be returned at the end of camp. All medications are kept with medical staff on camp grounds. No camper is allowed to keep medication in their bunk.

Does your child have difficulty sleeping or urinate in bed? If so, please explain how you handle this at home. *

Is your child able to swim without flotation devices? *

Yes

No

For girls: Has your child menstruated?

Yes

No

Is there any additional information that would aid our camp staff in taking care of your child? Do they have any behavior, physical, emotional, or mental health challenges we should be aware of?

Authorizations

Please agree to the following statements and sign below. *

This health history is correct to the best of my knowledge, and the camper named above has permission to engage in all camp activities as noted.

I certify that I am the camper's legal parent or guardian, and give permission for said camper to use camp transportation to participate in offsite activities.

I give consent for Camp Be'chol Lashon medical staff to dispense my child's prescription medications to him/her, as well as over-the-counter medications, sunscreen, and insect repellent.

I acknowledge and understand there are inherent risks associated with many camp activities. I will assume the risk associated therewith, whether known or unknown to me at this time. I recognize that my attendance at Camp Be'chol Lashon is a privilege and as a consideration for this privilege, I release Camp Be'chol Lashon, including its employees, agents, and trustees, from responsibility for my accidental physical injury, including death or illness, and loss of personal property while at camp or during Camp Be'chol Lashon sponsored travel to and from camp. This release is also intended to include all claims made by the family, estate, heirs, personal representative or assigns. I grant permission for my child to participate in all special trips off the camp property with the proper staff supervision.

I authorize Camp Be'chol Lashon staff to seek any medical care necessary for my child, including basic first aid on camp grounds or care at the nearest hospital, in case of an emergency. I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests, treatment; to maintain and/or release any medical records necessary for insurance purposes as outlined under HIPAA regulations; and to provide or arrange necessary related transportation for me or my child. In an emergency, I hereby give permission and authorize the physician selected by Camp Be'chol Lashon to secure and administer emergency medical treatment, including hospitalization and any other emergency medical procedures which may be needed for the person named herein. I authorize the physician or dentist to call in any necessary consultants in his/her discretion. It is understood that this consent is given in advance of any specific diagnosis or treatment being required, and is given to encourage those persons who have temporary custody of the minor, and said physician or dentist to exercise their best judgement as to the requirements of such diagnosis or medical, dental, or surgical treatment.

I hereby grant to Camp Be'chol Lashon the right to use, reproduce, and/or distribute photographs, films, videotapes, and sound recordings of my child, without compensation or approval rights, for use in material created for the purposes of promoting the activities of Camp Be'chol Lashon.

What concerns do you have about things at camp that you might not like? *

What are your favorite family traditions? *

Do you have favorite Jewish traditions? If so, what are they? *

Do you know anyone who will be at camp this summer? If so, who? *

Describe yourself with 5 different words: *

Code of Conduct

I pledge to do the following while at camp: *

I will physically and emotionally respect myself, my peers, staff, and the camp grounds.

I will ask a staff member for support if I am feeling challenged.

I will be open to learning more about myself and others.

I pledge to NOT do the following while at camp: *

I will NOT harm myself, my peers, staff, or the camp grounds.

I will NOT judge that which is new to me.

I will NOT leave my group or activity without permission.

I accept that if I fail to keep these pledges, I risk losing valuable camp privileges, including being at Camp Be'chol Lashon. Please sign electronically below in the presence of your parent(s) or guardian(s).

Website

Dates

Session 1: July 21 – July 28, 2019

Session 2: July 28 – August 4, 2019

Rates

One week: $1,300

Two weeks: $2,450

Camperships

We strive to provide every child with the opportunity to experience Camp Be’chol Lashon. Click here for information about several camp scholarship opportunities. Please call us at 415-386-2604 if you would like help in navigating this process.